Orthopedic Coding Alert

Question: Our surgeon did the following procedure:

The patient was explicitly instructed to be nonambulatory on the right lower extremity secondary to her right ankle fracture as well as her recent medial tibial plateau stress fracture, which was treated by another orthopedic surgeon. She was noncompliant and was ambulating full weight bearing due to her deconditioning of her upper extremity and obesity. She was seen in the office where it was shown to have complete disruption of the internal fixation. She was admitted to the hospital and was taken to the operating room for above-mentioned procedure.

The operative note reads as follows:

"The patient was taken to the operating room, laid in supine position where general anesthesia was administered. A tourniquet was placed to the proximal aspect of the right leg. It was not used during the procedure. The right leg was prepped and draped in a sterile manner. The lateral incision was opened and the hardware was removed. The medial two screws were also removed. The wound was then copiously irrigated. The hematoma was evacuated. The fracture was reduced and held with a bone clamp. The distal fibular plate extending the length of the plate from the previous by three holes were then placed in the distal fibula. One proximal compression screw was then utilized to hold the plate to the distal fibula. Two distal locking screws were then placed. A FiberWire TightRope was then placed crossing the distal tibial metaphysis and manner parallel to the ankle joint approximately 3 cm proximal. The syndesmosis was then reduced. Three proximal locking and then two more distal locking screws were then placed into the distal fibula. It was checked in 3 views, which were shown to be appropriately placed and fixated. The wound was then copiously irrigated, closed with 0 Vicryl and then staples as well as additional nylon for additional fixation of the skin. The medial malleolus was then addressed with a longitudinal incision over the distal medial metaphyseal flare. Blunt dissection was carried out to the periosteum and a hook plate with two proximal locking screws were then placed hooking the medial malleolus and reducing it under fluoroscopic visualization. One 4.0 fully threaded cancellous screw was then placed into the distal metaphysis engaging the plane pulling and reducing the fracture further. One proximal locking screw and one compression cancellous screw was then utilized proximally. It was then visualized showing and 3 views to be appropriately positioned. No evidence of loss of fixation and good alignment. There was a small posterior malleolar fragment, which was not reachable and nor affected the weight bearing surface of the distal tibia. This wound was then copiously irrigated and closed loosely with an 0 Vicryl then closed with nylon. Sterile bulky dressing was applied to the wound as well as a posterior splint. The patient was then awakened from anesthesia and transferred to PACU in stable condition."

How can we bill for the syndesmosis?

Maryland Subscriber

Answer: You should report code 27814 (Open treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli], includes internal fixation, when performed) as the procedure is more like a revision open reduction and internal fixation (ORIF) of a bimalleolar fraccture and code 27695 (Repair, primary, disrupted ligament, ankle; collateral) for the repair of the ligament. You report code 27829 (Open treatment of distal tibiofibular joint [syndesmosis] disruption, includes internal fixation, when performed) separately for the syndesmosis repair if a separate incision is made.